Annual Compliance Certification Form (for Part 70 Permits)

Page 1 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
INSTRUCTIONS FOR COMPLETING THE
TITLE V ANNUAL COMPLIANCE CERTIFICATION FORM
Information required to be included in the Annual Compliance Certification is located at
OKLAHOMA ADMINISTRATIVE CODE (OAC), Air Pollution Control, Title 252, Chapter
100-8-6(c)(5)(C)(i-v).
PART 1 - IDENTIFYING INFORMATION
Company and Facility Name Company and facility name as printed on the cover of
the permit.
Principal Facility Product The primary type of activity conducted by the facility
and SIC/NAICS and/or product produced with associated SIC/NAICS
code (visit www.osha.gov or www.census.gov for
additional information).
Physical Address The physical location of the facility.
Mailing Address Address where the facility receives mail.
Initial Title V Permit Number Number of the initial Title V permit issued to the
facility.
Issuance Date Date that the initial Title V permit was issued to the
facility, as indicated by the date of the signature of the
DEQ permitting authority. This date is used to
determine the Annual Compliance Certification cycle
and due date unless otherwise permitted by DEQ.
Permit Modification and/or When applicable, list permit numbers for all Title V
Renewal Number(s) permits, amendments, and other permit changes that
were federally enforceable (issued) during the
reporting period including construction permit
conditions.
Permit Modification and/or When applicable, issuance date for each permit listed
Renewal Issuance Date(s) in the previous data field.
Page 2 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
Certification Period Beginning and ending dates for the reporting period
covered by this form, normally encompassing a full
year. If the facility’s Title V permit is cancelled during
the reporting period, certification must be made for
the time in which the Title V permit was effective. The
certification is due no later than 30 days after each
anniversary date of the issuance of the initial Title V
permit unless otherwise permitted by DEQ.
Environmental Contact Person The environmental contact should be a person
familiar with the day-to-day operation of the facility
and should be available to be contacted by DEQ
personnel. The appropriate contact information
should be provided.
Responsible Official The definition of “responsible official” is specified in 40
C.F.R. § 70.2 and OAC 252:100-1-3, and is generally
summarized as:
 For a Corporation:
 Corporate Officer,
 Other person in charge of principal
business functions, or
 Duly authorized representative
responsible for overall operation of a
source (i.e. Plant Manager) if either:
o Facility employs more than 250
persons or has $25 million in
sales or expenditures, or
o Delegation of authority is
approved in advance by DEQ
 For a partnership or sole proprietorship:
 A general partner, or
 The proprietor, respectively
 For a public agency:
 Principal executive officer, or
 Ranking elected official
Appropriate contact information should be provided.
PART 2 – CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESS
A responsible official must print their name, sign, and date the certification of truth,
accuracy, and completeness using blue or black ink. A title must be included to ensure
that the signing party meets the criteria for responsible official as described above. A
Page 3 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
copy of the certification that includes the original signature of the responsible official
must be provided to DEQ.
PART 3 – ANNUAL COMPLIANCE CERTIFICATION DATA
Use the table to report the compliance status and methods or means used to determine
compliance with each federally enforceable permit term and condition effective during
the certification period. Those conditions that do not impose any affirmative compliance
obligations on the permit holder are not required to be included unless the source has
had to take action in reference to them (i.e. Permit Shield, authorization to operate
continuously, etc.). Copy the table provided as many times as necessary to cover all
applicable permit terms and conditions.
[A] Condition Identification
All federally enforceable permit terms and conditions effective during the certification
period should be identified under column [A].
[1] Permit Number and Condition Number
List the permit number and condition number for each permit term
effective during the certification period. For permit modifications and
renewals with conditions that are the same as previous Title V permits
also effective during the certification period, the same certification line may
be shared as illustrated in the following example (Table 1).
Table 1. Permit Condition Identification Example
[A]
Condition Identification
[1]
Permit and Condition Number
[2]
Applicable Requirement
2010-000-TV SpC 3
2010-000-TVR SpC 3
Fuel-burning equipment
shall be fired with natural gas
[2] Applicable Requirement
Briefly describe the requirement of each condition. If the requirement is
expressed as a numerical limitation or range of values, the description
should identify the limit. It is not necessary to copy the conditions
verbatim into the table.
[B] Compliance Determination Method(s), Information, and/or Facts
Identify the method(s) used for determining the compliance status of the source during
the certification period. If a source becomes aware of information that indicates a
Page 4 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
deviation from permit terms or an applicable requirement, even though the permit does
not specifically require the information, the source must consider the information,
identify and address it in the compliance certification, and certify accordingly.
DEQ has included a list of monitoring codes for your convenience (see Table 2 below).
The regulated community can use other monitoring codes if the codes used are
explained. If the source wishes to explain the method in narrative, they may choose to
do so.
Table 2. Monitoring Code Table
Monitoring
Code Short Description Example Activities
BMP Best Management Practice
-Practices generally recognized as “good
operational practice” or published as “best
management practice”
CEMS Continuous Emission Monitoring
System -Continuous Emission Monitoring System
CERMS Continuous Emission Rate
Monitoring System -Sulfuric acid plants
COMS Continuous Opacity Monitoring
System -Continuous Opacity Monitoring System
OMP Operations and Maintenance
Plan
-Operate equipment in accordance with
manufacturer’s recommendations
-Periodic replacement of paint booth filters
PEMS Predictive Emissions Monitoring
System -Predictive NOx monitor
PMS Parametric Monitoring System
-Record thermal oxidizer operating
temperature
-Record baghouse pressure drop
-Record scrubber flow rate and pH
RR Recordkeeping Requirement
-By-delivery fuel certification
-Track pollutant content (e.g., VOC, HAP)
-Calculate rolling emissions total
ST Stack Test -Testing using EPA approved method
VE Visible Emissions Monitoring -Daily visible emissions check
-Periodic Method 9 observations
VIN Visual Inspection -Periodic inspection of work practices
[C] Compliance Status
Identify either “Continuous” or “Intermittent” compliance status with respect to
each permit condition during the certification period as determined using the
method or means indicated.
Page 5 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
PART 4 – STANDARD CONDITIONS COMPLIANCE CERTIFICATION
[1] Standard Conditions Identification
Indicate which version(s) of the Standard Conditions were issued with each Title
V permit enforceable during the certification period by typing the Standard
Condition effective dates.
[2] Compliance Certification
If continuous compliance with all Standard Conditions enforceable during the
certification period was achieved, check the first box.
If compliance was intermittent for any of the Standard Conditions, check the
second box and list the condition(s) in the table. **If the source experienced
intermittent compliance for any permit term or condition during the certification
period, the source should consider their compliance status with Standard
Condition Section I. Duty to Comply.**
PART 5 – DEVIATION REPORTING
Identify the status of any deviations that occurred during the certification period
identified in Part 3 and Part 4, indicating “Yes” or “No” as to whether any of the
deviations have been previously reported (or identified by DEQ) and whether any of the
deviations have not been previously reported (or identified by DEQ).
Table 1 and Table 2: Deviation Summary and Deviation Details
Complete Table 1 for previously reported deviations with information used to
determine the duration and extent of the deviation(s) reported and/or incorporate
deviation reports by reference.
Complete Table 2 for previously unreported deviations with information to
determine the duration and extent of the deviation(s) reported.
Please mail an Annual Compliance Certification (DEQ Form 100-924) to each of the
following addresses:
Department of Environmental Quality
Attn: Air Quality Division Director
707 N. Robinson P.O. Box 1677
Oklahoma City, OK 73101-1677
US-EPA Region 6, Air Enforcement 6EN-A
1445 Ross Ave, Ste. 1200
Dallas, Texas 75202
Annual Compliance CertificationForm
Part 70 Permit
DEQ Form 100-924 Page 1 Adopted 1/3/2011
PART 1 - IDENTIFYING INFORMATION
Company Name
Facility Name
Principal Facility Product or
Business
Primary
SIC/NAICS
Physical Address
Mailing Address
Initial Title V Permit Number Issuance Date
Permit Modification and/or
Renewal Number(s)
Permit Modification
and/or Renewal
Issuance Date(s)
Certification Period
Environmental
Contact Person
Phone #
E-mail
Responsible Official Phone #
E-mail
PART 2 - CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESS
I certify, based on information and belief formed after reasonable inquiry, the statements and
information in this document are true, accurate, and complete.
Responsible Official Signature Date
Responsible Official Title
Annual Compliance Certification
DEQ Form 100-924 Page 2 Adopted 1/3/2011
PART 3 - ANNUAL COMPLIANCE CERTIFICATION DATA
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 3 Adopted 1/3/2011
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 4 Adopted 1/3/2011
PART 4 - STANDARD CONDITIONS COMPLIANCE CERTIFICATION
[1] Standard Conditions Dated:
[2]
By checking this box, the source certifies that they were in continuous compliance with all Standard Conditions contained
in the Title V permit(s) for the duration of the certification period. Method(s) used to determine compliance were those listed in
each condition.
By checking this box, the source certifies that they were in continuous compliance with all Standard Conditions contained
in the Title V permit(s) for the duration of the certification period EXCEPT for the conditions listed in the table below.
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 5 Adopted 1/3/2011
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 6 Adopted 1/3/2011
PART 5 - DEVIATION REPORTING
Question Yes (Y)
or No (N)
Are there any deviations that occurred during the certification period that were reported to or identified by DEQ during the
certification period?
If yes, you may incorporate any deviation reports by reference and/or complete Table 1.
Are there any deviations that occurred during the certification period that have not yet been reported to or identified by DEQ
that are being noted in this report?
If yes, complete Table 2.
Annual Compliance Certification
DEQ Form 100-924 Page 7 Adopted 1/3/2011
Table 1: Deviations that occurred during the certification period that were previously reported to or identified by DEQ
Term or
Condition
ID
Emission
Unit ID Pollutant Monitoring Method
& Frequency
Date(s) of
Deviation Duration Cause of Deviation Corrective Actions Taken
Annual Compliance Certification
DEQ Form 100-924 Page 8 Adopted 1/3/2011
Table 2: Deviations that occurred during the certification period that have not yet been reported to or identified by DEQ
Term or
Condition
ID
Emission
Unit ID Pollutant Monitoring Method
& Frequency
Date(s) of
Deviation Duration Cause of Deviation Corrective Actions Taken

Click tabs to swap between content that is broken into logical sections.

Page 1 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
INSTRUCTIONS FOR COMPLETING THE
TITLE V ANNUAL COMPLIANCE CERTIFICATION FORM
Information required to be included in the Annual Compliance Certification is located at
OKLAHOMA ADMINISTRATIVE CODE (OAC), Air Pollution Control, Title 252, Chapter
100-8-6(c)(5)(C)(i-v).
PART 1 - IDENTIFYING INFORMATION
Company and Facility Name Company and facility name as printed on the cover of
the permit.
Principal Facility Product The primary type of activity conducted by the facility
and SIC/NAICS and/or product produced with associated SIC/NAICS
code (visit www.osha.gov or www.census.gov for
additional information).
Physical Address The physical location of the facility.
Mailing Address Address where the facility receives mail.
Initial Title V Permit Number Number of the initial Title V permit issued to the
facility.
Issuance Date Date that the initial Title V permit was issued to the
facility, as indicated by the date of the signature of the
DEQ permitting authority. This date is used to
determine the Annual Compliance Certification cycle
and due date unless otherwise permitted by DEQ.
Permit Modification and/or When applicable, list permit numbers for all Title V
Renewal Number(s) permits, amendments, and other permit changes that
were federally enforceable (issued) during the
reporting period including construction permit
conditions.
Permit Modification and/or When applicable, issuance date for each permit listed
Renewal Issuance Date(s) in the previous data field.
Page 2 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
Certification Period Beginning and ending dates for the reporting period
covered by this form, normally encompassing a full
year. If the facility’s Title V permit is cancelled during
the reporting period, certification must be made for
the time in which the Title V permit was effective. The
certification is due no later than 30 days after each
anniversary date of the issuance of the initial Title V
permit unless otherwise permitted by DEQ.
Environmental Contact Person The environmental contact should be a person
familiar with the day-to-day operation of the facility
and should be available to be contacted by DEQ
personnel. The appropriate contact information
should be provided.
Responsible Official The definition of “responsible official” is specified in 40
C.F.R. § 70.2 and OAC 252:100-1-3, and is generally
summarized as:
 For a Corporation:
 Corporate Officer,
 Other person in charge of principal
business functions, or
 Duly authorized representative
responsible for overall operation of a
source (i.e. Plant Manager) if either:
o Facility employs more than 250
persons or has $25 million in
sales or expenditures, or
o Delegation of authority is
approved in advance by DEQ
 For a partnership or sole proprietorship:
 A general partner, or
 The proprietor, respectively
 For a public agency:
 Principal executive officer, or
 Ranking elected official
Appropriate contact information should be provided.
PART 2 – CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESS
A responsible official must print their name, sign, and date the certification of truth,
accuracy, and completeness using blue or black ink. A title must be included to ensure
that the signing party meets the criteria for responsible official as described above. A
Page 3 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
copy of the certification that includes the original signature of the responsible official
must be provided to DEQ.
PART 3 – ANNUAL COMPLIANCE CERTIFICATION DATA
Use the table to report the compliance status and methods or means used to determine
compliance with each federally enforceable permit term and condition effective during
the certification period. Those conditions that do not impose any affirmative compliance
obligations on the permit holder are not required to be included unless the source has
had to take action in reference to them (i.e. Permit Shield, authorization to operate
continuously, etc.). Copy the table provided as many times as necessary to cover all
applicable permit terms and conditions.
[A] Condition Identification
All federally enforceable permit terms and conditions effective during the certification
period should be identified under column [A].
[1] Permit Number and Condition Number
List the permit number and condition number for each permit term
effective during the certification period. For permit modifications and
renewals with conditions that are the same as previous Title V permits
also effective during the certification period, the same certification line may
be shared as illustrated in the following example (Table 1).
Table 1. Permit Condition Identification Example
[A]
Condition Identification
[1]
Permit and Condition Number
[2]
Applicable Requirement
2010-000-TV SpC 3
2010-000-TVR SpC 3
Fuel-burning equipment
shall be fired with natural gas
[2] Applicable Requirement
Briefly describe the requirement of each condition. If the requirement is
expressed as a numerical limitation or range of values, the description
should identify the limit. It is not necessary to copy the conditions
verbatim into the table.
[B] Compliance Determination Method(s), Information, and/or Facts
Identify the method(s) used for determining the compliance status of the source during
the certification period. If a source becomes aware of information that indicates a
Page 4 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
deviation from permit terms or an applicable requirement, even though the permit does
not specifically require the information, the source must consider the information,
identify and address it in the compliance certification, and certify accordingly.
DEQ has included a list of monitoring codes for your convenience (see Table 2 below).
The regulated community can use other monitoring codes if the codes used are
explained. If the source wishes to explain the method in narrative, they may choose to
do so.
Table 2. Monitoring Code Table
Monitoring
Code Short Description Example Activities
BMP Best Management Practice
-Practices generally recognized as “good
operational practice” or published as “best
management practice”
CEMS Continuous Emission Monitoring
System -Continuous Emission Monitoring System
CERMS Continuous Emission Rate
Monitoring System -Sulfuric acid plants
COMS Continuous Opacity Monitoring
System -Continuous Opacity Monitoring System
OMP Operations and Maintenance
Plan
-Operate equipment in accordance with
manufacturer’s recommendations
-Periodic replacement of paint booth filters
PEMS Predictive Emissions Monitoring
System -Predictive NOx monitor
PMS Parametric Monitoring System
-Record thermal oxidizer operating
temperature
-Record baghouse pressure drop
-Record scrubber flow rate and pH
RR Recordkeeping Requirement
-By-delivery fuel certification
-Track pollutant content (e.g., VOC, HAP)
-Calculate rolling emissions total
ST Stack Test -Testing using EPA approved method
VE Visible Emissions Monitoring -Daily visible emissions check
-Periodic Method 9 observations
VIN Visual Inspection -Periodic inspection of work practices
[C] Compliance Status
Identify either “Continuous” or “Intermittent” compliance status with respect to
each permit condition during the certification period as determined using the
method or means indicated.
Page 5 of 5 Annual Compliance Certification – Instructions Revised 1/3/2011
PART 4 – STANDARD CONDITIONS COMPLIANCE CERTIFICATION
[1] Standard Conditions Identification
Indicate which version(s) of the Standard Conditions were issued with each Title
V permit enforceable during the certification period by typing the Standard
Condition effective dates.
[2] Compliance Certification
If continuous compliance with all Standard Conditions enforceable during the
certification period was achieved, check the first box.
If compliance was intermittent for any of the Standard Conditions, check the
second box and list the condition(s) in the table. **If the source experienced
intermittent compliance for any permit term or condition during the certification
period, the source should consider their compliance status with Standard
Condition Section I. Duty to Comply.**
PART 5 – DEVIATION REPORTING
Identify the status of any deviations that occurred during the certification period
identified in Part 3 and Part 4, indicating “Yes” or “No” as to whether any of the
deviations have been previously reported (or identified by DEQ) and whether any of the
deviations have not been previously reported (or identified by DEQ).
Table 1 and Table 2: Deviation Summary and Deviation Details
Complete Table 1 for previously reported deviations with information used to
determine the duration and extent of the deviation(s) reported and/or incorporate
deviation reports by reference.
Complete Table 2 for previously unreported deviations with information to
determine the duration and extent of the deviation(s) reported.
Please mail an Annual Compliance Certification (DEQ Form 100-924) to each of the
following addresses:
Department of Environmental Quality
Attn: Air Quality Division Director
707 N. Robinson P.O. Box 1677
Oklahoma City, OK 73101-1677
US-EPA Region 6, Air Enforcement 6EN-A
1445 Ross Ave, Ste. 1200
Dallas, Texas 75202
Annual Compliance CertificationForm
Part 70 Permit
DEQ Form 100-924 Page 1 Adopted 1/3/2011
PART 1 - IDENTIFYING INFORMATION
Company Name
Facility Name
Principal Facility Product or
Business
Primary
SIC/NAICS
Physical Address
Mailing Address
Initial Title V Permit Number Issuance Date
Permit Modification and/or
Renewal Number(s)
Permit Modification
and/or Renewal
Issuance Date(s)
Certification Period
Environmental
Contact Person
Phone #
E-mail
Responsible Official Phone #
E-mail
PART 2 - CERTIFICATION OF TRUTH, ACCURACY, AND COMPLETENESS
I certify, based on information and belief formed after reasonable inquiry, the statements and
information in this document are true, accurate, and complete.
Responsible Official Signature Date
Responsible Official Title
Annual Compliance Certification
DEQ Form 100-924 Page 2 Adopted 1/3/2011
PART 3 - ANNUAL COMPLIANCE CERTIFICATION DATA
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 3 Adopted 1/3/2011
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 4 Adopted 1/3/2011
PART 4 - STANDARD CONDITIONS COMPLIANCE CERTIFICATION
[1] Standard Conditions Dated:
[2]
By checking this box, the source certifies that they were in continuous compliance with all Standard Conditions contained
in the Title V permit(s) for the duration of the certification period. Method(s) used to determine compliance were those listed in
each condition.
By checking this box, the source certifies that they were in continuous compliance with all Standard Conditions contained
in the Title V permit(s) for the duration of the certification period EXCEPT for the conditions listed in the table below.
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 5 Adopted 1/3/2011
[A]
Condition Identification
[B]
Compliance Determination
Method(s), Information, and/or Facts
[C]
Compliance
Status
Throughout
Period
[D]
Current
Compliance
Status
[1]
Permit and Condition Number
[2]
Applicable Requirement
Continuous
(C)
or
Intermittent
(I)
In Compliance
(C)
or
In Deviation
(D)
Annual Compliance Certification
DEQ Form 100-924 Page 6 Adopted 1/3/2011
PART 5 - DEVIATION REPORTING
Question Yes (Y)
or No (N)
Are there any deviations that occurred during the certification period that were reported to or identified by DEQ during the
certification period?
If yes, you may incorporate any deviation reports by reference and/or complete Table 1.
Are there any deviations that occurred during the certification period that have not yet been reported to or identified by DEQ
that are being noted in this report?
If yes, complete Table 2.
Annual Compliance Certification
DEQ Form 100-924 Page 7 Adopted 1/3/2011
Table 1: Deviations that occurred during the certification period that were previously reported to or identified by DEQ
Term or
Condition
ID
Emission
Unit ID Pollutant Monitoring Method
& Frequency
Date(s) of
Deviation Duration Cause of Deviation Corrective Actions Taken
Annual Compliance Certification
DEQ Form 100-924 Page 8 Adopted 1/3/2011
Table 2: Deviations that occurred during the certification period that have not yet been reported to or identified by DEQ
Term or
Condition
ID
Emission
Unit ID Pollutant Monitoring Method
& Frequency
Date(s) of
Deviation Duration Cause of Deviation Corrective Actions Taken